It’s Never The Hip Flexor

By James Noake

#ItsNeverTheHipFlexor: an exaggerated statement accompanying a number of my groin-orientated Twitter posts, but Social Media sometimes demands hyperbole and a bold statement to get a key point across, even though it’s become a bit of an ‘eye roll’ for some clinicians!

This hashtag line was born out of frustration having seen numerous patients in clinic, specifically endurance runners, with groin pain mismanaged and misdiagnosed variably as ‘tight’ hip flexors, hip flexor ‘strains’ or tendinitis.

My biggest concern was that the majority of these patients had a neck of femur stress reaction or fracture (NOFS#). The consequences of overlooking these can at best mean a delayed recovery or a forfeited marathon place, and at worst be catastrophic. In particular a lateral (tension side) NOFS# shouldn’t be missed, as these are at higher risk of non-union or propagating to full fracture if not offloaded at the earliest opportunity.

I have seen two runners in their 40s - who had been advised to continue training and work on their hip flexor stretching and strength work - sustain an acute displaced fracture during a marathon with a trivial stumble and mis-step. These both required surgery – one with screws, the other a total hip replacement. These procedures are not without risk and return to running rates ‘nosedive’ in those requiring an operation compared to conservative management, meaning that being vigilant and early identification of the problem is crucial with respect to your patients’ running longevity and to avoid significant complications.

Simply taking a comprehensive history and asking focused questions can be enough to avoid this diagnostic (and potentially medicolegal) trap.